Double-Layer Rotator Cuff Repair: Anatomic Reconstruction of the Superior Capsule and Rotator Cuff Improves Biomechanical Properties in Repairs of Delaminated Rotator Cuff Tears

Long head of the biceps tendon versatility in reconstructive shoulder surgery: a narrative review of arthroscopic techniques and their biomechanical principles with video presentation

The management of the long head of the biceps tendon (LHBT) during shoulder arthroscopy has been a subject of controversy for many years, with evolving discussions and trends. Despite long-standing debate, the nature of the surgical indication regarding how to treat concomitent LHBT injuries has undergone changes in recent years. It now extends beyond the timing of tenotomy to encompass considerations of alternative methods for preserving the LHBT, along with an ongoing exploration of how it can be effectively utilized in reconstructive shoulder surgery. Recent techniques describe approaches to using LHBT in a wide range of procedures, from shoulder instability to rotator cuff tears. Additionally, LHBT-based reconstructive techniques have surfaced for addressing what were formerly denoted as irreparable rotator cuff tears. While current literature provides detailed anatomical descriptions of the LHBT and many reports of novel, advanced techniques, there is still much debate regarding the decision-making process in each case. Because of the growing number of emerging techniques and the escalating debate in the subsequent paper, a decision has been made to present the current literature review concerning the potential utilization of LHBT in shoulder arthroscopy. In a dedicated video, we demonstrate the main arthroscopic techniques employed by the authors in their daily practice.

A Modified Arthroscopic Triple-row Repair Technique for L-shaped Delaminated Rotator Cuff Tears

OBJECTIVE

To compare the clinical outcomes of a modified arthroscopic triple-row (TR) repair technique with the suture bridge (SB) repair technique in treating L-shaped delaminated rotator cuff tears. Various surgical techniques for L-shaped delaminated rotator cuff tears have been reported, many of which aid in increasing the contact area and pressure of the rotator cuff. However, there is still debate over which technique yields superior results.

METHODS

From January 2017 to March 2020, 61 cases of L-shaped delaminated rotator cuff tears were included in this study. Of these, 34 cases underwent the modified arthroscopic triple-row repair technique, while 27 cases were addressed with the suture bridge repair technique. Functional assessment was conducted using the American Shoulder and Elbow Surgeons (ASES) score, the University of California Los Angeles (UCLA) shoulder score, the Constant score (CS), and the visual analogue scale (VAS) score. Magnetic Resonance Imaging (MRI) assessments for rotator cuff healing were performed at the 24-month postoperative mark. Statistical evaluations were conducted using SPSS for Windows (Version 25.0, IBM, Armonk, NY, USA), employing the Wilcoxon signed-rank test to compare preoperative and postoperative data and ROM differences, and the Mann-Whitney U test for statistical differences in clinical outcome scores between the two groups. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Comparative analysis of the preoperative and final follow-up scores revealed a substantial enhancement in shoulder function, as indicated by the ASES, UCLA, CS, and VAS scores, with statistical significance (p < 0.001). At both the preoperative stage and final follow-up, no notable differences were observed in ASES, UCLA, CS, and VAS scores between the two groups. However, the TR repair group exhibited lower VAS scores than the SB group at 1 and 3 months postoperatively. Active range of motion (ROM) showed significant improvement in both groups. No significant differences in ROM were noted between the two groups either before the surgery or at the final follow-up.

CONCLUSION

The study demonstrates that both the modified arthroscopic TR and SB techniques for L-shaped delaminated cuff tears yield satisfactory outcomes, with no significant differences in overall clinical performance. Notably, early postoperative pain management appears more effective with the modified TR technique, suggesting its potential for enhanced early recovery experiences. This technique's design, promoting securer fixation and optimal contact conditions, is implied to facilitate superior long-term healing, warranting further investigation into its long-term benefits.

Comparison of En Masse Repair versus Separate Double-Layer Repair for Delaminated Rotator Cuff Tears: A Systematic Review and Meta-Analysis

BACKGROUND

Delamination of cuff tendons has a negative impact on outcomes following arthroscopic rotator cuff repair (RCR). The purpose of this study is to compare en masse repair (EMR) and separate double-layer repair (SDLR) for delaminated rotator cuff tears.

METHODS

A systematic literature search was conducted on major databases (MEDLINE/PubMed, EMBASE, Cochrane Library, and Scopus) until 1 June 2023. Comparative studies with a minimum 24-month follow-up of patients undergoing arthroscopic RCR for delaminated tears were included. The outcomes assessed retear rates and functional outcomes.

RESULTS

Five eligible studies involving 325 cases were analyzed. The meta-analysis showed no significant difference in retear rates between SDLR and EMR for delaminated tears (OR = 0.73, 95% CI: 0.35-1.49). However, the meta-analysis demonstrated a significant intergroup difference in favor of the SDLR for the total Constant score (SMD = 0.68, 95% CI: 0.35 to 1.02), SST score (SMD = 0.37, 95% CI: 0.02 to 0.71), and postoperative range of abduction (SMD = 0.34, 95% CI: 0.03 to 0.64).

CONCLUSION

The evidence suggests that the SDLR in arthroscopic RCR for delaminated rotator cuff tears leads to improved short-term functional outcomes and range of motion compared to EMR. However, there is no significant difference in retear risk between the two approaches.

Outcomes After Double-Layer Repair Versus En Masse Repair for Delaminated Rotator Cuff Injury: A Systematic Review and Meta-analysis

Background

Delamination of rotator cuff tears during arthroscopic shoulder surgery has an incidence of 38% to 92%. Double-layer (DL) repair and en masse (EM) repair are most commonly used in this situation.

Purpose

To compare the clinical results of the DL versus EM repair techniques for delaminated rotator cuff tears using a meta-analysis.

Study Design

Systematic review; level of evidence, 3.

Methods

We identified relevant studies comparing the clinical results of DL and EM repair for delaminated rotator cuff injuries in the PubMed, Embase, and Cochrane databases after the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The primary outcomes were the Constant score and retear rate. Additionally, we compared other postoperative shoulder functional scores, shoulder range of motion, and visual analog scale (VAS) pain scores between the 2 suture methods using a meta-analysis. The mean difference (MD) was compared for continuous outcomes, and the odds ratios (ORs) were compared for categorical outcomes.

Results

Of the 197 studies initially identified, 6 studies were included in this analysis. There were significant differences in the Constant score (MD, 8.64 [95% CI, 4.47 to 12.8]; P < .05) and external rotation (MD, 5.10 [95% CI, 2.63 to 7.56]; P < .05) between the 2 techniques, with DL repair having superior outcomes. No significant differences were observed between the 2 techniques in forward flexion (MD, 0.62 [95% CI, -1.18 to 2.43]; P = .50), VAS pain (MD, -0.03 [95% CI, -0.34 to 0.27]; P = .84), or retear rate (OR, 0.73 [95% CI, 0.37 to 1.41]; P = .35).

Conclusion

Results of this review and meta-analysis suggest that DL repair was more beneficial than EM repair in terms of the Constant score and shoulder external rotation in patients with delaminated rotator cuff injuries.

Anatomic restoration of the articular deep layer is a definitive factor for repair status in delaminated rotator cuff tear

BACKGROUND

Recent studies have focused on the deep layer in delaminated rotator cuff tears. However, no studies have discussed the relationship between repair success and the properties of the deep layer. Herein, we aimed to analyze the intraoperative repair tension of the deep layer with respect to clinical outcomes and repair integrity and to evaluate the clinical results of delaminated rotator cuff tears after dual layer-specific repair.

METHODS

A total of 202 patients with delaminated rotator cuff tears had undergone dual layer-specific suture bridge repair; the mean follow-up duration was 28.6 (24-72) months. Intraoperatively, the repair tension of the deep layer was measured using a tensiometer, and mobility was ranked as easy or tight. After repair of the deep layer, the superficial layer tension was measured and ranked in a similar fashion. Clinical outcomes were evaluated using the Constant score, American Shoulder and Elbow Surgeons score, and subjective shoulder values. The relationship between retear and intraoperative qualitative factors of tendons was investigated. Prognostic factors for retear were analyzed using multiple logistic regression analyses.

RESULTS

Postoperative retears occurred in 11 (5.4%) patients. With regard to the deep layer, the tight mobility group had greater tear size, tendon retraction, and fatty infiltration of the supraspinatus and infraspinatus than the easy mobility group. No intergroup difference in postoperative retear rate was observed between the tight and easy deep-layer groups. Logistic regression analysis showed that fatty infiltration of the infraspinatus (odds ratio, 3.1; 95% confidence interval, 1.3-7.7; P = .013) and mobility of the superficial layer after deep layer repair (odds ratio, 8.1; 95% confidence interval, 1.7-38.1; P = .008) were predictors of retear.

CONCLUSION

Intraoperative mobility in the deep layer was not directly related to postoperative retear. Conversely, the quality of the infraspinatus concomitant with mobility of the superficial layer after deep layer repair significantly influenced repair integrity. Good clinical results were obtained even in cases with high repair tension of the deep layer.

Dynamic Superior Capsular Reconstruction for Irreparable Massive Rotator Cuff Tears: Histologic Analysis in a Rat Model and Short-term Clinical Evaluation

BACKGROUND

Superior capsular reconstruction (SCR) has been demonstrated to be a valuable treatment for patients with irreparable massive rotator cuff tears (IMRCTs). However, the torn medial supraspinatus (SSP) tendons, which acted as dynamic stabilizers, were left untreated in conventional SCR, and the dynamic force from the SSP tendon was not restored.

PURPOSE

To evaluate the effect of dynamic SCR (dSCR) on fascia-to-bone healing in a rat model, and to compare the short-term clinical effectiveness of dSCR and SCR using autologous fascia lata (FL) in patients with IMRCTs.

STUDY DESIGN

Controlled laboratory study and cohort study; Level of evidence, 3.

METHODS

A total of 50 rats were divided randomly into 2 groups: the dSCR group and the SCR group (25 rats per group). First, chronic IMRCTs were created, and then the torn tendons in both groups were subjected to SCR using autologous thoracolumbar fascial (TLF) grafts. The remnant of the SSP tendon was sutured to the medial part of the TLF graft in the dSCR group but not in the SCR group. Histologic sections were assessed at 1, 2, 4, 8, and 16 weeks postoperatively. In the clinical study, 22 patients (9 SCR, 13 dSCR) were analyzed. The recovery of shoulder function, including the active range of motion (ROM), visual analog scale (VAS), American Shoulder and Elbow Surgeons score, Constant score, and University of California Los Angeles score, acromiohumeral distance (AHD), and fatty infiltration, was evaluated before surgery and at the last follow-up.

RESULTS

Histologic analysis of the fascia-to-bone junction in the rat model showed that the TLF gradually migrated into tendon-like tissue over the rotator cuff defects in both groups, and the modified tendon maturation score of the fascia-to-bone interface in the dSCR group was higher than that in the SCR group at 4 weeks (12.20 ± 1.30 vs 14.60 ± 1.52; P = .004), 8 weeks (19.60 ± 1.14 vs 22.20 ± 1.10; P = .019), and 16 weeks (23.80 ± 0.84 vs 26.20 ± 0.84 P = .024). The dSCR group showed earlier fibrocartilage cell formation and angiogenesis. In the clinical study, all 22 patients completed a minimum of 12 months of follow-up after surgery, and the mean follow-up duration was 22.89 ± 7.59 months in the SCR group and 25.62 ± 7.32 months in the dSCR group. The patients in both groups showed significant improvements in terms of ROM, shoulder function scores, and AHD. At the last follow-up, abduction (56.67°± 27.39° vs 86.54°± 30.37°; P = .029), external rotation (25.00°± 9.35° vs 33.08°± 8.55°; P = .049), internal rotation cone rank (-2.78 ± 2.44 vs -4.38 ± 1.12; P = .049), VAS (-3.00 ± 0.87 vs -3.92 ± 0.95; P = .031) and Constant (47.89 ± 15.39 vs 59.15 ± 9.74; P = .048) scores, and the AHD improvement degree (3.06 ± 1.41 mm vs 4.38 ± 1.35 mm; P = .039) in the dSCR group were significantly improved compared with those in the SCR group. The results of fatty infiltration at the last follow-up showed that there was significant improvement compared with the preoperative results in both the conventional SCR (P = .036) and the dSCR (P = .001) groups. However, there were no significant differences between the 2 groups (P = .511).

CONCLUSION

dSCR can promote faster fascia-to-bone healing in a rat model, and the dSCR technique could provide a preferable treatment option for patients with IMRCTs.

CLINICAL RELEVANCE

dSCR might restore the dynamic of SSP in some sense and then improve the fatty infiltration in the SSP.

Delaminated Tears of the Rotator Cuff: MRI Interpretation with Clinical Correlation

(1) Background: A delaminated tear is described as a horizontal split in the tendon substance. This review summarizes the clinical and radiologic characteristics of delaminated tears of the rotator cuff. (2) Methods: Initial radiological characteristics of a delaminated tear include the horizontal component of a partial-thickness tear determined using magnetic resonance (MR) arthrography. As demonstrated using indirect MR arthrography, the tear gradually progresses to be defined as either horizontal intrasubstantial splitting of the bursal and articular layers or differential retraction of the bursal and articular layers. (3) Results: The existence of delaminated tears is a poor prognostic factor in functional and morphologic outcomes after the repair of rotator cuff tendons and many surgical techniques have been introduced to solve this problem. Although the presence of a delaminated tear does not affect the arthroscopic repair outcome, the presence of medium-to-large, retracted delaminated tears may be an adverse negative prognostic factor after single-row repair. (4) Conclusion: Advances in imaging and surgical techniques have improved the detection of delaminated rotator cuff tears. Preoperative identification of delaminated tears on magnetic resonance imaging is clinically important because tailored surgical repair techniques must be chosen for successful outcomes.

Rotator Cuff Delamination Is Associated With Increased Tendon Retraction and Higher Fatty Muscle Infiltration: A Comparative Study on Arthroscopy and Magnetic Resonance Imaging

PURPOSE

To investigate (1) tendon delamination according to different rotator cuff tear patterns as well as (2) the association of tendon retraction and fatty muscle infiltration with delamination of the rotator cuff. Furthermore, we aimed to establish the accuracy of magnetic resonance imaging for the detection of rotator cuff delamination.

METHODS

Magnetic resonance imaging scans of patients who underwent arthroscopic rotator cuff repair from 2013 to 2015 were retrospectively compared to intraoperative findings. Prevalences of tendon delamination, tendon retraction, and fatty muscle infiltration were categorized according to different rotator cuff tear patterns. For comparability of the amount of tendon retraction of delaminated and non-delaminated rotator cuff tears, we introduced the global retraction index, a description individually assessing tendon retraction in magnetic resonance imaging scans of all visible layers.

RESULTS

Of 349 shoulders, tendon delamination was observed in 231 patients (66.2%). Of these, rotator cuff delamination was most commonly seen in posterosuperior rotator cuff tears (84.6%). Delaminated rotator cuff tears presented with a significantly higher global retraction index (P < .001) as well as higher fatty muscle infiltration of the supraspinatus (P = .001) and infraspinatus (P = .001). Magnetic resonance imaging had only moderate accuracy (57.3%) to detect rotator cuff delamination, with a positive predictive value of 100% (95% confidence interval [CI] 95.6% to 100.0%) and a negative predictive value of 44.2% (95% CI 38.1% to 50.4%).

CONCLUSIONS

Tendon delamination was most commonly observed in posterosuperior rotator cuff tears. Delaminated rotator cuff tears showed a significantly greater tendon retraction as well as a higher amount of fatty muscle infiltration of the supraspinatus and infraspinatus. Magnetic resonance imaging has only moderate accuracy for detection of rotator cuff delamination.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Knotted Transosseous-Equivalent Technique for Rotator Cuff Repair Shows Superior Biomechanical Properties Compared With a Knotless Technique: A Systematic Review and Meta-analysis

PURPOSE

To compare the biomechanical properties of the knotted versus knotless transosseous-equivalent (TOE) techniques for rotator cuff repair (RCR).

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, and the Cochrane Library to identify studies that compared the biomechanical properties of knotted and knotless TOE RCR techniques. The search phrase used was as follows: (Double Row) AND (rotator cuff) AND (repair) AND (biomechanical). Evaluated properties included ultimate load to failure, cyclic displacement, stiffness, footprint characteristics, and failure mode.

RESULTS

Eight studies met the inclusion criteria, including a total of 67 specimens in each group. Of 6 studies reporting on ultimate load to failure, 4 found tendons repaired with the knotted TOE technique to experience significantly higher ultimate load to failure compared with knotless TOE repairs (knotted range, 323.5-549.0 N; knotless range, 166.0-416.8 N; P < .05). Of 6 studies reporting on failure stiffness, 2 found knotted TOE repairs to have significantly higher failure stiffness compared with knotless TOE repairs (knotted range, 30.0-241.8 N/mm; knotless range, 28.0-182.5 N/mm; P < .05), whereas 1 study found significantly higher failure stiffness in knotless TOE repairs compared with knotted TOE repairs (P = .039). Cyclic gap formation favored the knotted TOE group in 2 of 3 studies (knotted range, 0.6-5.2 mm; knotless range, 0.4-9.1 mm; P < .05). The most common mode of failure in both groups was suture tendon tear.

CONCLUSIONS

On the basis of the included cadaveric studies, rotator cuff tendons repaired via the knotted TOE technique display superior time-zero biomechanical properties, including greater ultimate load to failure, compared with rotator cuffs repaired via the knotless TOE technique. Suture tearing through the tendon remains a common failure method for both techniques.

CLINICAL RELEVANCE

The results of this systematic review provide helpful insight into the biomechanical differences between 2 popular techniques for RCR. Although these results should be carefully considered by surgeons who are using either of these techniques in the operating room, they should not be mistaken for direct clinical applicability because cadaveric studies may not directly correlate to clinical outcomes.

[Research progress of indication and treatment of graft in shoulder superior capsular reconstruction for rotator cuff tear]

Objective

To review the research progress of indication and treatment of graft in shoulder superior capsular reconstruction (SCR) for rotator cuff tear (RCT).

Methods

The literature related to shoulder SCR in recent years was extensively reviewed, and the anatomy, biomechanics, surgical indications, and treatment of graft in SCR were summarized.

Results

Superior capsule plays a role as a functional complex with rotator cuff, ligament, and whole capsule. SCR can effectively restore the superior stability of the shoulder. The indications of SCR include the irreparable massive RCT, massive RCT combined with pseudoparalysis shoulder, medium/large RCT with severe degenerative rotator cuff tissue, and dual-layer RCT. In order to achieve a better healing of tendon-bone in graft and decrease the rate of long-term graft retearing, it is essential to select an appropriate thickness graft, fix the graft in right intensity, and get a better capsular continuity.

Conclusion

The technique of SCR advanced to SCR for reinforcement and it is indicated from substantial massive RCT to severe degeneration of rotator cuff tissue. Graft treatment is the key step for a successful SCR.

Augmented Repair of Large to Massive Delaminated Rotator Cuff Tears With Autologous Long Head of the Biceps Tendon Graft: The Arthroscopic "Cuff-Plus" Technique

An anatomic and tension-free repair is the goal of arthroscopic rotator cuff repair. However, this purpose is not always achievable in large and massive tears, and sometimes, even when intraoperative results seem acceptable, clinical and radiologic outcomes can be disappointing shortly afterward. Superior capsule reconstruction has been claimed as a valid and viable joint-preserving option for treating irreparable rotator cuff tears. However, the role of the superior capsule in repairable cuff tears has also been questioned. The aim of this article is to present the so-called arthroscopic cuff-plus technique. This technique consists of superior capsule reconstruction using the proximal part of the long head of the biceps tendon associated with a tension-free repair of the rotator cuff tendons in large to massive delaminated tears.

Graft Tensioning in Superior Capsular Reconstruction Improves Glenohumeral Joint Kinematics in Massive Irreparable Rotator Cuff Tears: A Biomechanical Study of the Influence of Superior Capsular Reconstruction on Dynamic Shoulder Abduction

Background:

Superior capsular reconstruction (SCR) for massive, irreparable rotator cuff tears has become more widely used recently; however, ideal tensioning of the graft and the influence on joint kinematics remain unknown.

Purpose/Hypothesis:

The purpose of this study was to assess the effects of graft tensioning on glenohumeral joint kinematics after SCR using a dermal allograft. The hypothesis was that a graft fixed under tension would result in increased glenohumeral abduction motion and decreased cumulative deltoid forces compared with a nontensioned graft.

Study Design:

Controlled laboratory study.

Methods:

A total of 10 fresh-frozen cadaveric shoulders were tested using a dynamic shoulder simulator. Each shoulder underwent the following 4 conditions: (1) native, (2) simulated irreparable supraspinatus (SSP) tear, (3) SCR using a nontensioned acellular dermal allograft, and (4) SCR using a graft tensioned with 30 to 35 N. Mean values for maximum glenohumeral abduction and cumulative deltoid forces were recorded. The critical shoulder angle (CSA) was also assessed.

Results:

Native shoulders required a mean (±SE) deltoid force of 193.2 ± 45.1 N to achieve maximum glenohumeral abduction (79.8° ± 5.8°). Compared with native shoulders, abduction decreased after SSP tears by 32% (54.3° ± 13.7°; P = .04), whereas cumulative deltoid forces increased by 23% (252.1 ± 68.3 N; P = .04). The nontensioned SCR showed no significant difference in shoulder abduction (54.1° ± 16.1°) and required deltoid forces (277.8 ± 39.8 N) when compared with the SSP tear state. In contrast, a tensioned graft led to significantly improved shoulder abduction compared with the SSP tear state (P = .04) although abduction and deltoid forces could not be restored to the native state (P = .01). A positive correlation between CSA and maximum abduction was found for the tensioned-graft SCR state (r = 0.685; P = .02).

Conclusion:

SCR using a graft fixed under tension demonstrated a significant increase in maximum shoulder abduction compared with a nontensioned graft; however, abduction remained significantly less than the intact state. The nontensioned SCR showed no significant improvement in glenohumeral kinematics compared with the SSP tear state.

Clinical Relevance:

Because significant improvement in shoulder function after SCR may be expected only when the graft is adequately tensioned, accurate graft measurement and adequate tension of at least 30 N should be considered during the surgical procedure. SCR with a tensioned graft may help maintain sufficient acromiohumeral distance, improve clinical outcomes, and reduce postoperative complications.

Shoulder biomechanics in normal and selected pathological conditions

The stability of the glenohumeral joint depends on soft tissue stabilizers, bone morphology and dynamic stabilizers such as the rotator cuff and long head of the biceps tendon. Shoulder stabilization techniques include anatomic procedures such as repair of the labrum or restoration of bone loss, but also non-anatomic options such as remplissage or tendon transfers.

Rotator cuff repair should restore the cuff anatomy, reattach the rotator cable and respect the coracoacromial arch whenever possible. Tendon transfer, superior capsular reconstruction or balloon implantation have been proposed for irreparable lesions.

Shoulder rehabilitation should focus on restoring balanced glenohumeral and scapular force couples in order to avoid an upward migration of the humeral head and secondary cuff impingement. The primary goal of cuff repair is to be as anatomic as possible and to create a biomechanically favourable environment for tendon healing.

Cite this article: EFORT Open Rev 2020;5:508-518. DOI: 10.1302/2058-5241.5.200006

Arthroscopic Superior Capsule Reconstruction and Rotator Cuff Repair to Restore Static and Dynamic Stability of the Shoulder

OBJECTIVE

Treatment of massive irreparable rotator cuff tears (RCT) has shown limited clinical success and a variety of subsequent complications. Superior capsule reconstruction (SCR) has been proved to reestablish superior stability but does not restore the dynamic force or shoulder kinematics. There are numerous reports of the short-term failure of SCR grafts at the glenoid side, which relate to the non-biological healing of grafts. To restore both dynamic and static stability and to provide biologic augmentation, an integrated procedure for massive irreparable RCT using an Achilles tendon-bone allograft (ATBA) was developed.

METHOD

This was a retrospect study completed between October 2019 and April 2020. A 71-year-old woman with massive and irreparable rotator cuff tears was enrolled in our study. The ATBA was folded into a double-layer structure. The superior layer (proximal portion) served as a bridge patch to dynamic the glenohumeral joint, while the inferior layer (distal portion) served as the superior capsule to restore static stability of glenohumeral joint. To enhance biologic healing on the glenoid side, we fixed the calcaneus of the graft on the superior-posterior side of the superior glenoid rim. The recovery of shoulder function (including strength, range of motion, acromiohumeral interval, and fatty infiltration) was assessed at 6 months postoperation.

RESULT

At 6-month follow-up, the patient's strength had improved significantly (from abduction of grade 3 preoperatively to grade 4 at 6 months). Radiographic analysis showed an increase in the acromiohumeral interval from 3 to 7 mm. Magnetic resonance imaging revealed an intact graft, with the thickness of the ligament part maintained (at 6-7 mm). Most importantly, recovery of atrophy and fatty infiltration of the supraspinatus were observed. No graft tears were observed on the glenoid side.

CONCLUSION

This technique could provide a preferable treatment option by restoring shoulder kinematics and augmentating biological healing for patients with massive irreparable RCT.

Knotless Anchor Fixation for Transosseous Meniscal Root Repair Using Suture Tape Is Inferior Compared With Button or Screw Fixation: A Biomechanical Study

Background

A 2 mm-wide ultrahigh-molecular-weight polyethylene (UHMWPE) tape improves the contact pressure at root repair sites compared with high-strength suture and provides a stronger repair construct. UHMWPE tape is commonly used in rotator cuff repair, and fixation is often achieved with knotless suture anchors. The optimal method for tape fixation for meniscal root repair has not been established.

Hypothesis

The use of suture anchors for the tibial fixation of 2-mm UHMWPE tape transosseous root repairs will lead to better biomechanical performance compared with other fixation methods.

Methods

The medial meniscal posterior root attachment in 25 porcine knees was divided, and a standardized transtibial root repair was performed using 2-mm UHMWPE tape. The testing was performed by cyclic loading followed by load to failure. Tibial fixation was randomized to 5 tibial fixation types: (1) cortical fixation button, (2) pound-in suture anchor with screw-down interference suture locking, (3) tap-in suture anchor with inner locking plug, (4) postscrew, and (5) postscrew and washer.

Results

There was no difference in displacement during cyclic loading between tibial fixation groups except for a highly significant difference in the maximum load at failure. Repairs in both suture anchor fixation groups all failed by tape slippage at relatively low loads (median, 145 and 116 N, respectively). Repairs tied over a cortical button, postscrew, or screw and washer failed by tape breakage at loads of 431, 405, and 528 N.

Conclusion

For meniscal root repairs with 2-mm UHMWPE tape, use of suture anchors offers weaker fixation compared with tying over a button or postscrew/washer. While suture anchor fixation may be adequate for nonweightbearing postoperative protocols, it may not allow for more accelerated weightbearing.

Delaminated Rotator Cuff Tears Showed Lower Short-term Retear Rates After Arthroscopic Double-Layer Repair Versus Bursal Layer-Only Repair: A Randomized Controlled Trial

BACKGROUND

The rotator cuff is known to consist of 2 macroscopically visible layers that have different biomechanical properties. Sometimes the inferior layer may be neglected during rotator cuff repair. However, it is controversial whether double-layer (DL) repair is superior to single-layer (SL) repair in terms of retear rate and outcome.

PURPOSE

To investigate whether DL as compared with SL repair could decrease retear rates after arthroscopic reconstruction of posterosuperior rotator cuff tears.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 70 patients were 1:1 randomized to receive an arthroscopic DL reconstruction (study group: DL suture-bridge repair) or SL reconstruction (control group: SL suture-bridge repair) for posterosuperior tears of the rotator cuff between 2.0 and 3.5 cm of the footprint detachment. Exclusion criteria were subscapularis tendon rupture (Lafosse >1°), fatty muscular infiltration >2°, and nondelaminated tendons. Tendon integrity according to Sugaya, fatty degeneration, and muscular atrophy were evaluated by magnetic resonance tomography. Pre- and postoperative evaluations included the Constant score, range of motion, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, subjective shoulder value, and postoperative satisfaction with the procedure. Complications were monitored throughout the study.

RESULTS

Ninety percent of patients (n = 34, DL; n = 29, SL) were followed-up. There were no significant group differences regarding baseline characteristics and pre- and postoperative fatty degeneration of the supraspinatus and atrophy of the supraspinatus and infraspinatus. The rate of magnetic resonance-verified intact repairs (Sugaya grades 1 + 2) was significantly higher in the DL group (70.6%) than in the SL group (44.8%; P = .045). One patient in the control group with a retear underwent revision. All functional and subjective scores improved significantly pre- to postoperatively in both groups (P < .05). No significant group differences were detected regarding postoperative Constant score, forward flexion, external rotation, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, subjective shoulder value, and visual analog scale and between intact and retorn tendons. The majority of patients were very satisfied or satisfied with their arthroscopic procedure (DL, 94.1%; SL, 92.9%).

CONCLUSION

This randomized controlled trial showed significantly lower retear rates after DL repair as compared with SL repair in delaminated rotator cuff tears. Clinical short-term outcome was not different between the DL and SL repair groups.

REGISTRATION

NCT003362320 (ClinicalTrials.gov identifier).

The knotless cinch-bridge technique for delaminated rotator cuff tears leads to a high healing rate and a more favorable short-term clinical outcome than suture-bridge repair

PURPOSE

To compare functional outcomes and magnetic resonance image (MRI) tendon integrity following either the suture bridge or the knotless cinch-bridge technique used for arthroscopic double-layer rotator cuff repair.

METHODS

37 prospectively enrolled patients (46-76 years), who were treated with arthroscopic double-layer rotator cuff repair (group 1: suture bridge n = 20, group 2: cinch bridge n = 17) were clinically and radiographically assessed before and at an average of 24.0 ± 4.7 months after the procedure. Shoulder function was evaluated by the constant score (CS), range of motion, and various patient-related scores. Repaired tendon integrity was evaluated by MRI. Peri- and postoperative complications were recorded.

RESULTS

All functional and patient-related scores significantly improved from pre- to postoperative. Significantly better postoperative CS (P = 0.037), flexion (P < 0.001), and abduction (P = 0.009) were detected after arthroscopic cinch compared to suture-bridge repair. The mean CS improvements from baseline to follow-up were not significantly different between the groups (n.s.). Patient-related scores did not show any statistical significant differences. The MRI healing rate following arthroscopic double-layer repair with the suture- and cinch-bridge technique was 95% and 94%, respectively. Fatty infiltration regarding the supraspinatus and infraspinatus increased in 55% and 35% (group 1) and in 53% and 48% (group 2), respectively. Muscle hypotrophy remained stable in all patients. Overall, 92% of the patients were very satisfied or satisfied with the procedure. No complications were detected.

CONCLUSIONS

Arthroscopic knotless double-layer rotator cuff repair with the cinch-bridge technique showed higher CS, forward flexion, and abduction values, as well as similar patient-related short-term outcome and MRI integrity compared to the suture-bridge technique. These results highlight the potential importance of less tendon strangulation for better clinical short-term outcome.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

A Modified SpeedBridge Technique for Retracted or Delaminated Rotator Cuff Repairs

Treatment of full-thickness rotator cuff tears vary in surgical technique dependent on the amount of retraction of the rotator cuff and/or delamination of the soft tissue. The described technique addresses both of those concerns. We present a modification of the SpeedBridge technique used to address retracted or delaminated repairs and effectively expand the indications for use of the double-row knotless technique. In this modification, the reduction is performed by an initial anchor with several stay sutures providing provisional reduction of the tissue in a controlled fashion. This is followed by compression through a standard double-row technique.

No healing improvement after rotator cuff reconstruction augmented with an autologous periosteal flap

PURPOSE

To show descriptive clinical and magnetic resonance (MR) imaging results after an additional periosteal flap augmentation in mini-open rotator cuff reconstruction and to evaluate potential healing improvement at long-term follow-up.

METHODS

Twenty-three patients with degenerative rotator cuff tears were followed after receiving a mini-open single-row repair with a subtendinous periosteal flap augmentation. Data were collected preoperatively, after 12 months and after 11 years. Clinical examination, simple shoulder test (SST), Constant-Murley Score (CS), ultrasonography examination and 3T MR imaging were performed.

RESULTS

Out of 23 patients, 20 were available for short-term and 19 for final follow-up at a median of 11.5 years (range 10.4-13.0). Questions answered with "yes" in SST improved from baseline 5.0 (range 1.0-8.0) to short 10.5 (range 8.0-12.0) and final follow-up 12.0 (range 7.0-12.0). CS improved from 53.5 (range 25.0-66.0) to 80.8 (range 75.9-89.3) and finally to 79.8 points (range 42.3-95.4). Improvement was highly significant (p < 0.05). Severe retears were found in 9/19 patients. Ossifications along the refixed tendon were noticed in 8/19 cases. Ossifications did not correlate with clinical outcome. At final follow-up, patients with retears seemed likely to have lower strength values in CS (mean ± SD) than patients without retears (7.3 ± 4.1 vs. 12.8 ± 5.3; p < 0.05).

CONCLUSION

No positive effect on improving healing response in rotator cuff refixation with a periosteal flap augmentation could be found. Retear rate is comparable to that of conventional rotator cuff refixation in the published literature. Ossifications along the tendon, without negatively affecting the clinical outcome, were seen. This invasive technique cannot be advised and should not be used anymore.

LEVEL OF EVIDENCE

IV.

Arthroscopic Knotless Separate Layer Transosseous Equivalent Repair of Delaminated Rotator Cuff Tears

Delamination of rotator cuff tears presents a challenge for surgeons. Recognizing and repairing such a complex tear pattern often require innovative approaches to achieve an anatomic restoration of footprint. In this Technical Note, we described our preferred method that anatomically repairs both layers of delaminated rotator cuff tear separately in a knotless transosseous equivalent technique. Two sutures are placed to the articular layer in a cinch stitch configuration. Then, closed-loop end sutures are passed through both layers while keeping the closed-loop end at the working portal. The free ends of cinch stitches are loaded to anchors with a preloaded fiber tape loop, which is placed to the medial row while approximating the articular layer onto its footprint. Fiber tapes are then shuttled through both layers of tendon with the help of a previously placed closed-loop suture. Finally, the lateral row anchors are placed while fiber tapes are tensioned in a cross-bridge configuration. We believe that this technique may facilitate uneventful healing of delaminated rotator cuffs by providing the biomechanical properties of transosseous equivalent repair.